Basic Information
| Provider Information | |||||||||
| NPI: | 1699393090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEIMLICH | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4445 LAKE FOREST DR | ||||||||
| Address2: | STE 600 | ||||||||
| City: | BLUE ASH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452423744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135693741 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1945 CEI DR | ||||||||
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| City: | BLUE ASH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452425664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139845133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2020 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT.006876 | OH | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.